NCLEX-RN
Psychosocial Integrity NCLEX Questions Questions
Extract:
Question 1 of 5
A client with superficial varicose veins states to the nurse, 'I hate these things. They're so ugly. I wish I could get them to go away.' Which therapeutic response would be most appropriate for the nurse to make to the client?
Correct Answer: C
Rationale: The client expressing distress about physical appearance has a risk for an altered body image. The nurse assesses the client's knowledge and self-management of the condition as a means of empowering the client and helping him or her adapt to the body change. Options 1 and 4 are not therapeutic. Option 2 focuses only on the cosmetic aspect of varicose veins.
Question 2 of 5
The spouse of a dying client states to the nurse, 'I don't think I can come anymore and watch her die. It's chewing me up too much!' Which is the most therapeutic response the nurse should make to the spouse?
Correct Answer: A
Rationale: The most therapeutic response is the one that is empathetic and that reflects the nurse's understanding of the client's, in this case, the husband's, stress and emotional pain. In the correct option, the nurse suggests that the client take time for himself. Option 2 is an example of a nontherapeutic and judgmental attitude that places blame. Option 3 makes statements that the nurse cannot know are true (the client's wife may not in fact know if the husband visits), and it predicts feelings of guilt, which is inappropriate. Option 4 fosters dependency and gives advice, which is nontherapeutic.
Question 3 of 5
A client who has undergone successful femoral-popliteal bypass grafting of the leg states to the nurse, 'I hope everything goes well after this and that I don't lose my leg. I'm so afraid that I'll have gone through this for nothing.' Which most therapeutic response should the nurse make to the client?
Correct Answer: C
Rationale: Clients frequently fear that they will ultimately lose a limb or become debilitated in some other way. Option 3 acknowledges the client's concerns and empowers the client to improve his or her health, which will ultimately reduce concern about the risk of complications. Option 1 feeds into the client's anxiety and is not therapeutic. Option 2 gives false reassurance. Option 4 is meant to be reassuring, but it offers no suggestions to empower the client.
Question 4 of 5
The nurse is caring for a dying client who states, 'Will you be the executor of my will?' How should the nurse best respond to this client?
Correct Answer: D
Rationale: The client's question reflects his thoughts about the will and how to obtain an executor, but the question does not reveal why the client is asking the nurse to be executor, and it also does not address other important information. In option 4, the nurse seeks clarification while acknowledging the client's statement. Most agencies do not allow the nurse to be the executor of a client's will (option 3). The other options fail to regard the potential consequences, think critically, or explore the client's motivation and needs.
Question 5 of 5
A client with a diagnosis of valvular heart disease is being considered for mechanical valve replacement. Which circumstance is essential to assess before the surgery is performed?
Correct Answer: B
Rationale: Mechanical valves carry the associated risk of thromboemboli, which require long-term anticoagulation with warfarin sodium. No data in the question indicate that physical demands exist in the client's lifestyle. Not all clients who undergo cardiac surgery require cardiac rehabilitation. Body image problems are important but not critical.